The reports of the novel coronavirus from Wuhan, China, in December 2019 immediately presented health systems around the world with new challenges [1-3]. The challenges brought by the emergence of the COVID-19 pandemic were unprecedented, and most countries’ health systems were stretched beyond capacity, even among the richer nations. It was evident from the onset that health systems would be stretched to capacity due to the rapid number of infected people requiring hospitalization [4]. The impact of this new virus on healthcare delivery can be broadly categorised into two categories; firstly, the impact on the infrastructure of the health systems defined by the structural, contextual material resources, excluding people, and secondly, the impact on the HCWs.

For some of the most affected countries (e.g., USA), the COVID-19 pandemic highlighted significant gaps in their private and public healthcare service provision. In the USA, the demand for increased acute care in some primary centres threatened long-term viability with crippling financial losses. Furthermore, the pandemic disproportionately impacted the Black and Hispanic communities, who had more cases and deaths even though they constituted only 13% and 18% of the total population, respectively [5]. Similar to the USA, in European countries worst hit by the pandemic, such as Italy, France, Spain, and the United Kingdom, inherent gaps in their health systems were exposed by the COVID-19 pandemic. The largely decentralised public health systems of Italy and Spain found it extremely difficult to coordinate activities in certain regions [6, 7]. More than the inability to streamline healthcare provision to those who needed it, several European health systems also suffered a shortage of personal protective equipment (PPE) and intensive care equipment [8, 9]. These challenges hampered HCWs’ ability to provide adequate patient care.

The pandemic has highlighted the need to enhance health systems' capacity to provide improved and cost-effective healthcare to all sectors of the population. Health systems need to build resilience for future COVID-19 pandemic waves [10]. The South African health system has dealt with a quadruple disease burden for decades [11]. This is likely to be compounded by the COVID-19 pandemic, and maintaining routine healthcare services requires a balance to be struck by a resilient health system. However, in South Africa, there are numerous strains on the health system due to COVID-19, with HCW capacity being overstretched and unable to function effectively [12].

Previous studies report that HCWs are likely to experience increased psychological distress, general anxiety about personally getting infected, and anxiety about the risk of infecting their families and friends [13]. With the progression of the pandemic, burnout became widespread among HCWs as they were unable to take time off due to the overburdened health systems [14]. It became increasingly evident that health facilities and health systems in several countries were unable to cope and adapt. In certain instances, HCWs were redeployed to where they were most needed but did not receive adequate training in their new roles [15]. Perceptions of HCWs about the health system are influenced by these structural and contextual factors as well as the more personal attitudinal motivations [16]. Additionally, factors such as long working hours in the public sector, absence of appraisals of recognition for employees who work hard [17], staff shortages, poor working conditions [18], lack of adequate training, poor communication and hierarchical relationships also have an impact on how HCWs view the health system [16, 19, 20].

The South African experience was similar to the rest of the world, wherein there was an urgent mobilization of HCWs who had to absorb rapidly developing scientific and public health information, adapt and immediately action this information in constrained health facilities [21]. Despite these interventions, South Africa has to date the highest number of COVID-19 cases and deaths in Africa. To maintain essential and optimal health services during a pandemic, it is important that the HCWs’ wellbeing and emotional resilience are not negatively impacted.

Perceiving the health system as being able to manage the pandemic can be viewed as a proxy for optimism and confidence in the collective efficacy of the national health system. The beliefs of a group of people in their collective efficacy impact their function as a whole [22]. The optimism of HCWs is interlinked with resilience and self-efficacy. It is also associated with seeking social support, finding practical solutions, higher performance, and improved patient satisfaction, and during crisis situations, optimism can lead to improved morbidity outcomes [22]. This paper, therefore, examines factors associated with HCWs’ perception of the South African health system’s capability for managing COVID-19 in the early stages of the pandemic.

This study found that approximately one-fifth (22.0%) of HCWs believed that the South African health system has the ability to manage the COVID-19 pandemic. When the same question was asked to South African residents in another study, two in five (40.7%) indicated that the country’s health system was able to manage the COVID-19 pandemic [24]. Healthcare workers’ positive views of the health system’s capability can reflect optimism or confidence in the collective efficacy of the national health system.

A study in Romania Sava [28] found low HCWs’ confidence (24.0%) in the health system to manage the pandemic, while Finland, Norway and Denmark reported high HCWs’ confidence (78.0%; 56% and 86.0%, respectively) in their health systems [29-31], thereby indicative of the disparate viewpoints between countries with different health systems and economies. In this study, low confidence in the health system’s response to the epidemic might be due to low trust in HCWs themselves or in their peers or possibly a lack of resilience to face workplace challenges or epidemic response in general [32]. Resilience, self-efficacy and coping strategies, therefore, need to be enhanced in HCWs, particularly in the subgroups whose confidence in the health system is lower.

Male HCWs reported greater confidence that the health system could manage the COVID-19 pandemic than female HCWs, which could be linked to males’ tendency to downplay risk [33]. Furthermore, the job roles, patient experiences, coping, mental health risks and personal commitments of HCWs differ by gender [34], and are linked to optimism and self-efficacy during health crises. There is a disproportionate distribution of race/population groups in the South African health worker force by professional category, years of experience, and job roles. However, after adjustment for professional category, sex, and age, perceptions of the health system’s capability were higher among Black African HCWs compared to other race groups. The factors associated with these differences need to be further understood.

Older HCWs and those who were confident in their knowledge about COVID-19 reported greater confidence in the national health system’s capability. Literature shows that older HCWs have more experience, which contributes to their higher confidence [35]. Experience in one’s job role in the healthcare sector contributes to an enhanced understanding of the health system, its capabilities and limitations. Furthermore, HCWs who are older, more experienced and working in senior roles might be less prone to panic in crisis situations, thereby explaining their optimistic perceptions of the health system’s capability.

Medical practitioners were less confident of the health system management in the pandemic than nurses, which should be interpreted by considering their different roles and experiences during the pandemic. It is likely that medical practitioners were already under pressure when consulting patients due to the existing quadruple burden of disease in South Africa [12] and were seeing challenges within the health system, thereby explaining their limited confidence in the health system’s management of COVID-19. Healthcare workers in other sectors, i.e., not in public and or private sectors, reported higher confidence in the health system’s capability. These HCWs included researchers and academics who were less frequently patient-facing. Therefore, they may not directly encounter or see the challenges in individual health facilities and may have a broader aggregated perspective of the national COVID-19 health response. South Africans with higher risk perceptions were less confident that their communities complied with the country’s lockdown regulations [36]. Healthcare workers who perceived themselves as being vulnerable to contracting COVID-19 may have lower self-efficacy and perceive the threat of the pandemic as very large.

The Western Cape and Free State provinces had the highest proportions of HCWs reporting the health system would manage the COVID-19 pandemic, while Mpumalanga province had the lowest. During the initial phase of the pandemic, higher infection rates were recorded in the Western Cape than other provinces. It is likely that HCWs in the Western Cape had higher confidence and self-efficacy in managing the epidemic from having dealt with more cases daily than the other provinces [23].

Despite immense improvements in the health system since 1994, there are still several service delivery challenges. These include unequal (human) resource distribution between the public/private sector and urban/rural localities [37], slow progress in health system restructuring [38], the ongoing disease burden [11], and poor goal setting, leadership and management. It is vital to address the structural challenges in the health system to improve the working conditions for HCWs.

While HCWs face exhaustion from longer working shifts, risk of infection and transmission to families, anxiety and stress, and limited resources including PPE, HCWs continue to provide patient care. As the greatest assets of our health systems, effective support for HCWs is essential, especially during a pandemic. Their challenges, needs and concerns must be understood, so that despite the ongoing COVID-19 pandemic, the fragile health system can still cope [12].

This study has some limitations. Healthcare workers with no access to the internet and technology as well as HCWs from health facilities with a high number of COVID-19 patients had a limited chance of participating in the online survey. To correct this bias, the survey data were benchmarked to the distribution of South Africa’s HCWs population by age, sex, population group, and province. This may allow generalizability of the findings of this study to the national population of HCWs in South Africa. Despite these limitations, the sample size for this study was relatively large, and it represented all major health professional categories in the country.

In the early days of the epidemic, most HCWs felt that the health system would not cope with COVID-19. Healthcare workers’ experience (a proxy for HCW’s age), work sector, professional category, confidence in knowledge about COVID, and risk perception were key factors affecting HCWs' perception of the health system's capability. It is important to build resilience and foster hope and optimism among HCWs while minimizing ongoing personal or workplace risks. Health systems strengthening and continuous professional development will contribute to improving collective efficacy among HCWs.

TM conceptualised the paper, conducted the analysis, and interpreted the results. TM, TMa, SS, ND, RS, and IN drafted the manuscript. TM, TMa, SS, ND, RS, IN, MM, MMo, and PR contributed to interpreting the results and editing the manuscript. All authors read and approved the final manuscript before submission.